Adult living donor liver transplantation: Perspectives from 100 liver transplant surgeons

Abstract

The involvement of healthy living donors and the degree of technical difficulty make adult living donor liver transplantation (LDLT) different from any other surgical procedure. We surveyed 100 liver transplant surgeons to assess their views on the complex issues raised by LDLT. Data were collected at meetings on LDLT and by electronic mail. The study instrument was divided into general, donor, surgeon, recipient, and donor and recipient issues. Subjects provided the projected 1-year survival threshold that they would require for the recipient before they would perform LDLT. They listed the three topics that they thought were most critical for transplant fellows to know about LDLT. A majority agreed that transplant programs have a duty to their patients to offer LDLT, that the increasing success of the procedure will expand indications for liver transplantation, and that the risk to the donor causes them a moral dilemma. There was more divergence of opinion regarding who should have the final say about a potential donor's candidacy, whether it is difficult for donors to comprehend the risks of the procedure, and whether repeat cadaveric transplantations should be offered for failed LDLT performed for extended indications. Surgeons' median recipient survival threshold was a conservative 79%. Priorities for educating trainees focused on understanding complications and risks, technical factors, and ethical concerns such as putting the donor first. represents an exciting advance in liver transplantation. Right lobe donation provides a means of increasing the availability of donor organs, while affording control over waiting time for liver transplantation, allograft quality, and preservation time. The procedure is technically challenging at a time when liver transplantation has become routine.Reported outcomes of LDLT are excellent. Recipient complications have decreased with experience, 1 and recipient survival is similar to that observed in transplantations performed using cadaveric donors. 2,3 After recovering from donation, living donors reported higher health-related quality of life on a number of different domains assessed by the SF-36, compared with norms for the population in the United States. 4,5

Should living donor liver transplantation be part of every liver transplant program?

“…In this survey 72% of responders considered that transplant programs have a duty to their patients to offer adult LDLT [34]. There is general agreement however that requirements need to go further with LDLT.…”

“…The question as to whether LDLT should be part of every liver transplant program was partly addressed in an interesting survey of 100 liver transplant surgeons published in 2003 [34]. In this survey 72% of responders considered that transplant programs have a duty to their patients to offer adult LDLT [34].…”

Live liver donors’ risk thresholds: risking a life to save a life

“…Another important limitation concerned the possibility that potential donors might not have fully understood the risks associated with donation as the thresholds for the risks for morbidity and mortality in this study were outside the range considered sensible by any health care provider. Although the present study was carried out following a standardized interview process and the numerical literacy of all participants was tested, participant preferences were measured only once.…”

“…However, LDLT is a technically complex procedure that absorbs substantial human and financial resources and is ethically controversial because of the risks to donors . There is still some disagreement regarding the ethics surrounding LDLT and there is uncertainty on the range of perioperative morbidity and mortality risks that living liver donors (LLDs) will consider acceptable . To investigate some of these issues, a prospective study was designed to assess potential LLDs’ inclinations towards LDLT and to measure the strength of their choices.…”

Choosing Among Living-Donor and Cadaveric Livers

“…There are also potential psychiatric issues for the living donors related to organ donation (Beresford 2004) as living donors are typically related to the recipient (Thalheimer and Capra 2002). In a recent survey among transplant surgeons, 77% of them indicated that the risk to the donor causes the surgeons a moral dilemma (Cotler et al 2003). All of these studies suggest that, all things being equal, there is a disutility associated with using a living-donor liver rather than a cadaveric liver for transplantation.…”